Valvular Heart Disease Guidelines Pocket Cards & App

Valvular Heart Disease GUIDELINES Pocket Guide

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American Heart Association

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Key Points

Patients with VHD may present with a heart murmur, symptoms, or incidental findings of valvular abnormalities on noninvasive testing.
The initial evaluation should include a detailed history and physical exam, ECG, chest x-ray, and transthoracic echocardiogram.
Decisions about treatment are based primarily on the presence or absence of symptoms, severity of VHD, and response of the ventricle to pressure or volume overload imposed by VHD.
VHD requires a multidisciplinary team and approach for its diagnosis and management.
Reasons for valve intervention are to improve symptoms, prolong survival, and reduce the risk of complications.
An evaluation of the surgical or interventional risk for each individual patient should be performed if intervention is indicated which includes a standard surgical risk score, along with consideration of comorbidites, frailty, and procedure specfic impediments.
Follow-up of patients with VHD is important to assess symptom status, provide patient education, and monitor disease severity, typically with periodic echocardiography.

Table 1. The Heart Valve Team

Recommendations	COR	LOE
Patients with severe VHD should be evaluated by a multidisciplinary Heart Valve Team when intervention is considered.	I	C
Consultation with or referral to a Heart Valve Center of Excellence is reasonable when discussing treatment options for asymptomatic patients with severe VHD, patients who may benefit from valve repair versus valve replacement, or patients with multiple comorbidities for whom valve intervention is considered.	IIa	C

Table 2. Stages of Progression of VHD

Stage	Definition	Description
A	At risk	Patients with risk factors for development of VHD
B	Progressive	Patients with progressive VHD (mild-to-moderate severity and asymptomatic)
C	Asymptomatic severe	Asymptomatic patients who meet the criteria for severe VHD: C1: Asymptomatic patients with severe VHD in whom the left or right ventricle remains compensated C2: Asymptomatic patients with severe VHD, with decompensation of the left or right ventricle
D	Symptomatic severe	Patients who have developed symptoms as a result of VHD

Table 3. Risk Assessment Combining STS Risk Estimate, Frailty, Major Organ System Dysfunction, and Procedure-Specific Impediments

Type	Low Risk (Must Meet ALL Criteria in This Column)	Intermediate Risk (Any 1 Criterion in This Column)	High Risk (Any 1 Criterion in This Column)	Prohibitive Risk (Any 1 Criterion in This Column)
STS PROM^a	<4% AND	4%-8% OR	>8% OR	Predicted risk with surgery of death or major morbidity (all-cause) OR
Frailty^b	None AND	1 index (mild) OR	≥2 indices (moderate to severe) OR	>50% at 1 y OR
Major organ system compromise not to be improved postoperatively^c	None AND	1 organ system OR	No more than 2 organ systems OR	≥3 organ systems OR
Procedure-specific impediment^d	None	Possible procedure-specific impediment	Possible procedure-specific impediment	Severe procedure-specific impediment

^a Use of the STS PROM to predict risk in a given institution with reasonable reliability is appropriate only if institutional outcomes are within 1 standard deviation of STS average observed/expected ratio for the procedure in question.

^b Seven frailty indices: Katz Activities of Daily Living (independence in feeding, bathing, dressing, transferring, toileting, and urinary continence) and independence in ambulation (no walking aid or assist required or 5-meter walk in <6 s). Other scoring systems can be applied to calculate no, mild-, or moderate-to-severe frailty.

^c Examples of major organ system compromise: Cardiac—severe LV systolic or diastolic dysfunction or RV dysfunction, fixed PHTN; CKD stage 3 or worse; pulmonary dysfunction with FEV1 <50% or DLCO2 <50% of predicted; CNS dysfunction (dementia, Alzheimer’s disease, Parkinson’s disease, stroke with persistent physical limitation); GI dysfunction—Crohn’s disease, ulcerative colitis, nutritional impairment, or serum albumin <3.0; cancer—active malignancy; and liver—any history of cirrhosis, variceal bleeding, or elevated INR in the absence of VKA therapy.

^d Examples: tracheostomy present, heavily calcified ascending aorta, chest malformation, arterial coronary graft adherent to posterior chest wall, or radiation damage.

Evaluation

Table 4. Initial Diagnostic Testing

Recommendations	COR	LOE
TTE is recommended in the initial evaluation of patients with known or suspected VHD to confirm the diagnosis, establish etiology, determine severity, assess hemodynamic consequences, determine prognosis, and evaluate for timing of intervention.	I	B
TTE is recommended in patients with known VHD with any change in symptoms or physical examination findings.	I	C
Periodic monitoring with TTE is recommended in asymptomatic patients with known VHD at intervals depending on valve lesion, severity, ventricular size, and ventricular function.	I	C
Cardiac catheterization for hemodynamic assessment is recommended in symptomatic patients when noninvasive tests are inconclusive or when there is a discrepancy between the findings on noninvasive testing and physical examination regarding severity of the valve lesion.	I	C
Exercise testing is reasonable in selected patients with asymptomatic severe VHD to confirm the absence of symptoms, or assess the hemodynamic response to exercise, or determine prognosis.	IIa	B

Table 5. Frequency of Echocardiograms in Asymptomatic Patients With VHD and Normal LV Function

Stage	AS ^a	AR	MS	MR
Progressive (stage B)	Every 3-5 y (mild severity: Vmax 2.0-2.9 m/s) Every 1-2 y (moderate severity: Vmax 3.0-3.9 m/s)	Every 3-5 y (mild severity) Every 1-2 y (moderate severity)	Every 3-5 y (MVA >1.5 cm²)	Every 3-5 y (mild severity) Every 1-2 y (moderate severity)
Severe (stage C)	Every 6-12 mo (Vmax ≥4 m/s)	Every 6-12 mo Dilating LV: more frequently	Every 1-2 y (MVA 1.0-1.5 cm²) Once every year (MVA <1.0 cm ²)	Every 6-12 mo Dilating LV: more frequently

Patients with mixed valve disease may require serial evaluations at intervals earlier than recommended for single valve lesions.
^a With normal stroke volume.

Table 6. Anticoagulation for Atrial Fibrillation (AF) in Patients With VHD (2017)

Recommendations	COR	LOE
Anticoagulation with a vitamin K antagonist (VKA) is indicated for patients with rheumatic mitral stenosis (MS) and AF.	I	B-NR
Anticoagulation is indicated in patients with AF and a CHA²DS²-VASc score of ≥2 with native aortic valve disease, tricuspid valve (TV) disease, or mitral regurgitation (MR).	I	C-LD
It is reasonable to use a direct oral anticoagulant (DOAC) as an alternative to a VKA in patients with AF and native aortic valve disease, tricuspid valve disease, or MR and a CHA²DS²-VASc score of ≥2.	IIa	C-LD

Native Valvular Heart Disease

Table 7. Stages of Valvular Aortic Stenosis (AS)

Stage	Definition	Valve Anatomy	Valve Hemodynamics	Hemodynamic Consequences	Symptoms
A	At risk of AS	Bicuspid aortic valve (or other congenital valve anomaly) Aortic valve sclerosis	Aortic V max <2 m/s	None	None
B	Progressive AS	Mild-to-moderate leaflet calcification of a bicuspid or trileaflet valve with some reduction in systolic motion or Rheumatic valve changes with commissural fusion	Mild AS: Aortic V max 2.0–2.9 m/s or ∆P mean <20 mm Hg Moderate AS: Aortic V max 3.0–3.9 m/s or ∆P mean 20–39 mm Hg	Early LV diastolic dysfunction may be present Normal left ventricular ejection fraction (LVEF)	None

C: Asymptomatic severe AS

Stage	Definition	Valve Anatomy	Valve Hemodynamics	Hemodynamic Consequences	Symptoms
C1	Asymptomatic severe AS	Severe leaflet calcification or congenital stenosis with severely reduced leaflet opening	Aortic V max ≥4 m/s or ∆P mean ≥40 mm Hg Aortic valve area (AVA) typically ≤1.0 cm² (or AVAi ≤0.6 cm²/m²) Very severe AS: Aortic V max ≥5 m/s or ∆P mean ≥60 mm Hg	LV diastolic dysfunction Mild LV hypertrophy Normal LVEF	None: Exercise testing is reasonable to confirm symptom status
C2	Asymptomatic severe AS with LV dysfunction	Severe leaflet calcification or congenital stenosis with severely reduced leaflet opening	Aortic V max ≥4 m/s or ∆P mean ≥40 mm Hg AVA typically ≤1.0 cm² (or AVAi ≤0.6 cm²/m²)	LVEF <50%	None

D: Symptomatic severe AS

Stage	Definition	Valve Anatomy	Valve Hemodynamics	Hemodynamic Consequences	Symptoms
D1	Symptomatic severe high- gradient AS	Severe leaflet calcification or congenital stenosis with severely reduced leaflet opening	Aortic V max ≥4 m/s or ∆P mean ≥40 mm Hg AVA typically ≤1.0 cm² (or AVAi ≤0.6 cm²/m²) but may be larger with mixed AS/AR	LV diastolic dysfunction LV hypertrophy Pulmonary hypertension (PHTN) may be present	Exertional dyspnea or decreased exercise tolerance Exertional angina Exertional syncope or presyncope
D2	Symptomatic severe low-flow/low-gradient AS with reduced LVEF	Severe leaflet calcification with severely reduced leaflet motion	AVA ≤1.0 cm² with resting aortic V max <4 m/s or ∆P mean <40 mm Hg Dobutamine stress echocardiography (DSE) shows AVA ≤1.0 cm² with V max ≥4 m/s at any flow rate	LV diastolic dysfunction LV hypertrophy LVEF <50%	Heart failure (HF) Angina Syncope or presyncope
D3	Symptomatic severe low-gradient AS with normal LVEF or paradoxical low-flow severe AS	Severe leaflet calcification with severely reduced leaflet motion	AVA ≤1.0 cm² with aortic V max <4 m/s or ∆P mean <40 mm Hg Indexed AVA ≤0.6 cm²/m² and Stroke volume index <35 mL/m² Measured when patient is normotensive (systolic blood pressure [BP] <140 mm Hg)	Increased LV relative wall thickness Small LV chamber with low stroke volume Restrictive diastolic filling LVEF ≥50%	HF Angina Syncope or presyncope

Aortic Stenosis

Table 8. Evaluation and Treatment in Patients With AS

Diagnostic Testing

Recommendations	COR	LOE
TTE is indicated in patients with signs or symptoms of AS or a bicuspid aortic valve for accurate diagnosis of the cause of AS, hemodynamic severity, LV size and systolic function, and for determining prognosis and timing of valve intervention.	I	B
Low-dose dobutamine stress testing using echocardiographic or invasive hemodynamic measurements is reasonable in patients with stage D2 AS with all of the following: Calcified aortic valve with reduced systolic opening; LVEF <50%; Calculated valve area ≤1.0 cm²; and Aortic velocity <4.0 m/s or ∆Pmean <40 mm Hg.	I	B
Exercise testing is reasonable to assess physiological changes with exercise and to confirm the absence of symptoms in asymptomatic patients with a calcified aortic valve and aortic velocity ≥4.0 m/s or ∆Pmean ≥40 mm Hg (stage C).	IIa	B
Exercise testing should *NOT* be performed in symptomatic patients with AS when the aortic velocity is ≥4.0 m/s or ∆Pmean is ≥40 mm Hg (stage D).	III: Harm	B

Medical Therapy

Recommendations	COR	LOE
Hypertension in patients at risk for developing AS (stage A) and in patients with asymptomatic AS (stages B and C) should be treated according to standard GDMT, started at a low dose and gradually titrated upward as needed with frequent clinical monitoring.	I	B
Vasodilator therapy may be reasonable if used with invasive hemodynamic monitoring in the acute management of patients with severe decompensated AS (stage D) with NYHA class IV HF symptoms.	IIb	C
Statin therapy is *NOT* indicated for prevention of hemodynamic progression of AS in patients with mild-to-moderate calcific valve disease (stages B-D).	III: No Benefit	A

Table 9. Indications for AVR in Patients With AS

Recommendations	COR	LOE
AVR is recommended in symptomatic patients with severe AS (stage D1) with: Decreased systolic opening of a calcified or congenitally stenotic aortic valve; and Aortic velocity ≥4.0 m/s or ∆Pmean ≥40 mm Hg; and Symptoms of HF, syncope, exertional dyspnea, angina, or presyncope by history or on exercise testing.	I	B
AVR is recommended for asymptomatic patients with severe AS (stage C2) and LVEF <50% with decreased systolic opening of a calcified aortic valve with an aortic velocity ≥4.0 m/s or ∆Pmean ≥40 mm Hg.	I	B
AVR is indicated for patients with very severe AS (stage C or D) when undergoing cardiac surgery for other indications when there is decreased systolic opening of a calcified aortic valve and aortic velocity ≥4.0 m/s or ∆Pmean ≥40 mm Hg.	I	B
AVR is reasonable for asymptomatic patients with severe AS (stage C1) with: Decreased systolic opening of a calcified valve; Aortic velocity ≥5.0 m/s or ∆Pmean ≥60 mm Hg; Low surgical risk.	IIa	B
AVR is reasonable in apparently asymptomatic patients with severe AS (stage C1) with: A calcified aortic valve; Aortic velocity 4.0-4.9 m/s or ∆Pmean of 40-59 mm Hg; An exercise test demonstrating decreased exercise tolerance or a fall in systolic BP.	IIa	B
AVR is reasonable in symptomatic patients with low-flow/low-gradient severe AS with reduced LVEF (stage D2) with a: Calcified aortic valve with reduced systolic opening; Resting valve area ≤1.0 cm²; Aortic velocity <4 m/s or ∆Pmean<40 mm Hg; LVEF <50%; and Low-dose dobutamine stress study that shows aortic velocity ≥4 m/s or ∆Pmean ≥40 mm Hg with valve area ≤1.0 cm² at any dobutamine dose.	IIa	B
AVR is reasonable in symptomatic patients with low-flow/low-gradient severe AS (stage D3) with LVEF ≥50%, a calcified aortic valve with significantly reduced leaflet motion, and a valve area ≤1.0 cm² only if clinical, hemodynamic, and anatomic data support valve obstruction as the most likely cause of symptoms and data recorded when the patient is normotensive (systolic BP <140 mm Hg) indicate: An aortic velocity <4 m/s or ∆Pmean <40 mm Hg; A stroke volume index <35 mL/m²; and An indexed valve area ≤0.6 cm²/m².	IIa	C
AVR is reasonable for patients with moderate AS (stage B) with an aortic velocity 3.0-3.9 m/s or ∆Pmean 20-39 mm Hg who are undergoing cardiac surgery for other indications.	IIa	C
AVR may be considered for asymptomatic patients with severe AS (stage C1) with aortic velocity ≥4.0 m/s or ∆Pmean ≥40 mm Hg if the patient is at low surgical risk and serial testing shows an increase in aortic velocity ≥0.3 m/s/y.	IIb	C

Table 10. Choice of Intervention

Recommendations	COR	LOE
For patients in whom transcatheter aortic valve replacement (TAVR) or high-risk surgical AVR is being considered, a heart valve team consisting of an integrated, multidisciplinary group of healthcare professionals with expertise in VHD, cardiac imaging, interventional cardiology, cardiac anesthesia, and cardiac surgery should collaborate to provide optimal patient care.	I	C
Surgical AVR is recommended for symptomatic patients with severe AS (Stage D) and asymptomatic patients with severe AS (Stage C) who meet an indication for AVR when surgical risk is low or intermediate. (Modified recommendation for 2017)	I	B-NR
Surgical AVR or TAVR is recommended for symptomatic patients with severe AS (Stage D) and high risk for surgical AVR, depending on patient-specific procedural risks, values, and preferences. (Modified recommendation for 2017)	I	A
TAVR is recommended for symptomatic patients with severe AS (Stage D) and a prohibitive risk for surgical AVR who have a predicted post-TAVR survival >12 months. (Modified recommendation for 2017)	I	A
TAVR is a reasonable alternative to surgical AVR for symptomatic patients with severe AS (Stage D) and an intermediate surgical risk, depending on patient-specific procedural risks, values, and preferences. (New recommendation for 2017)	IIa	B-R
Percutaneous aortic balloon dilation may be considered as a bridge to surgical AVR or TAVR for symptomatic patients with severe AS.	IIb	C
TAVR is NOT recommended in patients in whom existing comorbidities would preclude the expected benefit from correction of AS.	III: No Benefit	B

Figure 1. Choice of TAVR Versus Surgical AVR in the Patient With Severe Symptomatic AS (2017)

Figure 2. Indications for AVR in Patients with AS

Aortic Regurgitation

Table 11. Stages of Chronic Aortic Regurgitation (AR)

Stage	Definition	Valve Anatomy	Valve Hemodynamics	Hemodynamic Consequences	Symptoms
A	At risk of AR	Bicuspid aortic valve (or other congenital valve anomaly) Aortic valve sclerosis Diseases of the aortic sinuses or ascending aorta History of rheumatic fever or known rheumatic heart disease IE	AR severity:none or trace	None	None
B	Progressive AR	Mild-to-moderate calcification of a trileaflet valve, bicuspid aortic valve (or other congenital valve anomaly) Dilated aortic sinuses Rheumatic valve changes Previous IE	Mild AR: Jet width <25% of LVOT; Vena contracta <0.3 cm; RVol <30 mL/beat; RF <30%; ERO <0.10 cm²; Angiography grade 1 Moderate AR: Jet width 25%-64% of LVOT; Vena contracta 0.3-0.6 cm; RVol 30-59 mL/beat; RF 30%-49%; ERO 0.10-0.29 cm²; Angiography grade 2	Normal LV systolic function Normal LV volume or mild LV dilation	None
C	Asymptomatic severe AR	Calcific aortic valve disease Bicuspid valve (or other congenital abnormality) Dilated aortic sinuses or ascending aorta Rheumatic valve changes IE with abnormal leaflet closure or perforation	Severe AR: Jet width ≥65% of LVOT; Vena contracta >0.6 cm; Holodiastolic flow reversal in the proximal abdominal aorta; RVol ≥60 mL/beat; RF ≥50%; ERO ≥0.3 cm²; Angiography grade 3 -4 ; In addition, diagnosis of chronic severe AR requires evidence of LV dilation	C1: Normal LVEF (≥50%) and mild-to-moderate LV dilation (LVESD ≤50 mm) C2: Abnormal LV systolic function with depressed LVEF (<50%) or severe LV dilatation (LVESD >50 mm or indexed LVESD >25 mm/m²)	None; exercise testing is reasonable to confirm symptom status
D	Symptomatic severe AR	Calcific valve disease Bicuspid valve (or other congenital abnormality) Dilated aortic sinuses or ascending aorta Rheumatic valve changes Previous IE with abnormal leaflet closure or perforation	Severe AR: Doppler jet width ≥65% of LVOT; Vena contracta >0.6 cm; Holodiastolic flow reversal in the proximal abdominal aorta; RVol ≥60 mL/beat; RF ≥50%; ERO ≥0.3 cm²; Angiography grade 3 -4 ; In addition, diagnosis of chronic severe AR requires evidence of LV dilation	Symptomatic severe AR may occur with normal systolic function (LVEF ≥50%), mild-to-moderate LV dysfunction (LVEF 40%-50%), or severe LV dysfunction (LVEF <40%) Moderate-to-severe LV dilation	Exertional dyspnea or angina or more severe HF symptoms

Table 12. Diagnosis, Medical Therapy, and Intervention in Patients With Chronic AR

Recommendations	COR	LOE
TTE is indicated in patients with signs or symptoms of AR (stages A-D) for accurate diagnosis of the cause of regurgitation, regurgitant severity, and LV size and systolic function, and for determining clinical outcome and timing of valve intervention.	I	B
TTE is indicated in patients with dilated aortic sinuses or ascending aorta or with a bicuspid aortic valve (stages A and B) to evaluate the presence and severity of AR.	I	B
CMR is indicated in patients with moderate or severe AR (stages B-D) and suboptimal echocardiographic images for the assessment of LV systolic function, systolic and diastolic volumes, and measurement of AR severity.	I	B

Medical Therapy

Recommendations	COR	LOE
Treatment of hypertension (systolic BP >140 mm Hg) is recommended in patients with chronic AR (stages B and C), preferably with dihydropyridine calcium channel blockers or ACE inhibitors/ARBs.	I	B
Medical therapy with ACE inhibitors/ARBs and beta blockers is reasonable in patients with severe AR who have symptoms and/or LV dysfunction (stages C2 and D) when surgery is not performed because of comorbidities.	IIa	B

Surgical Intervention

Recommendations	COR	LOE
AVR is indicated for symptomatic patients with severe AR regardless of LV systolic function (stage D).	I	B
AVR is indicated for asymptomatic patients with chronic severe AR and LV systolic dysfunction (LVEF <50%) at rest (stage C2) if no other cause for systolic dysfunction is identified.	I	B
AVR is indicated for patients with severe AR (stage C or D) while undergoing cardiac surgery for other indications.	I	C
AVR is reasonable for asymptomatic patients with severe AR with normal LV systolic function (LVEF ≥50%) but with severe LV dilation (LVESD >50 mm or indexed LVESD >25 mm/m²) (stage C2).	IIa	B
AVR is reasonable in patients with moderate AR (stage B) while undergoing surgery on the ascending aorta, CABG, or MV surgery.	IIa	C
AVR may be considered for asymptomatic patients with severe AR and normal LV systolic function at rest (LVEF ≥50%, stage C1) but with progressive severe LV dilation (LVEDD >65 mm) if surgical risk is low.	IIb	C

Figure 3. Indications for AVR for Chronic AR

Bicuspid Aortic Valve and Aortopathy

Table 13. Diagnosis and Intervention in Patients With Bicuspid Aortic Valve and Aortopathy

Diagnosis

Recommendations	COR	LOE
An initial TTE is indicated in patients with a known bicuspid aortic valve to evaluate valve morphology, to measure the severity of AS and AR, and to assess the shape and diameter of the aortic sinuses and ascending aorta for prediction of clinical outcome and to determine timing of intervention.	I	B
Aortic magnetic resonance angiography or CT angiography is indicated in patients with a bicuspid aortic valve when morphology of the aortic sinuses, sinotubular junction, or ascending aorta cannot be assessed accurately or fully by echocardiography.	I	C
Serial evaluation of the size and morphology of the aortic sinuses and ascending aorta by echocardiography, CMR, or CT angiography is recommended in patients with a bicuspid aortic valve and an aortic diameter >4.0 cm, with the examination interval determined by the degree and rate of progression of aortic dilation and by family history. In patients with an aortic diameter >4.5 cm, this evaluation should be performed annually.	I	C

Surgical Intervention

Recommendations	COR	LOE
Operative intervention to repair the aortic sinuses or replace the ascending aorta is indicated in patients with a bicuspid aortic valve if the diameter of the aortic sinuses or ascending aorta is >5.5 cm	I	B
Operative intervention to repair the aortic sinuses or replace the ascending aorta is reasonable in patients with bicuspid aortic valves if the diameter of the aortic sinuses or ascending aorta is >5.0 cm and a risk factor for dissection is present (family history of aortic dissection or if the rate of increase in diameter ≥0.5 cm per year).	IIa	C
Replacement of the ascending aorta is reasonable in patients with a bicuspid aortic valve who are undergoing aortic valve surgery because of severe AS or AR if the diameter of the ascending aorta is >4.5 cm.	IIa	C

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Valvular Heart Disease GUIDELINES Pocket Guide

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Key Points

Table 1. The Heart Valve Team

Table 2. Stages of Progression of VHD

Table 3. Risk Assessment Combining STS Risk Estimate, Frailty, Major Organ System Dysfunction, and Procedure-Specific Impediments

Evaluation

Table 4. Initial Diagnostic Testing

Table 5. Frequency of Echocardiograms in Asymptomatic Patients With VHD and Normal LV Function

Table 6. Anticoagulation for Atrial Fibrillation (AF) in Patients With VHD (2017)

Native Valvular Heart Disease

Table 7. Stages of Valvular Aortic Stenosis (AS)

C: Asymptomatic severe AS

D: Symptomatic severe AS

Aortic Stenosis

Table 8. Evaluation and Treatment in Patients With AS

Diagnostic Testing

Medical Therapy

Table 9. Indications for AVR in Patients With AS

Table 10. Choice of Intervention

Figure 1. Choice of TAVR Versus Surgical AVR in the Patient With Severe Symptomatic AS (2017)

Figure 2. Indications for AVR in Patients with AS

Aortic Regurgitation

Table 11. Stages of Chronic Aortic Regurgitation (AR)

Table 12. Diagnosis, Medical Therapy, and Intervention in Patients With Chronic AR

Medical Therapy

Surgical Intervention

Figure 3. Indications for AVR for Chronic AR

Bicuspid Aortic Valve and Aortopathy

Table 13. Diagnosis and Intervention in Patients With Bicuspid Aortic Valve and Aortopathy

Diagnosis

Surgical Intervention

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